AV fistulas and LVH

I am pre-dialysis. I had an AV fistula created in my upper left arm in March, and over time, it has matured to the point where I can see my veins pulsate and grow. It’s damn creepy. In my research on dialysis and its effects on the heart (particularly the left ventricle), I read somewhere that just having an AV fistula in and of itself can raise the risk of LVH. Is that true?

I am planning to do NxStage at home; I understand the overwhelming benefits of daily dialysis. I would ideally like to do home nocturnal but I don’t think it will be the best fit for me and my husband. NxStage done each night seems like it would be ideal for me. I am on the transplant list and want to remain as healthy as possible while waiting. I am in good health apart from the fsgs that is has been attacking my kidneys for 20 years. I would be grateful for any advice/tips that you could share with me on ways to keep myself in good working order once I have to begin dialysis. How do I best protect my heart/cardiovascular system? What are the biggest bugbears of dialysis and what can I do to minimize their effects?

Thank you so much.

Dear MooseMom

Thank you for your question.

While I am sorry to hear that you have FSGS and that after a 20 year battle against declining renal function, you are going to progress to dialysis soon. However, despite that, you are in a lucky minority - and sadly it is still a minority - to have had a good (though in your own words ‘creepy’) and, from the sound of it, a very sound AV fistula already in place, ready to go and well-functioning. This already speaks volumes for a good management strategy by your team and, believe it or not, you are in a far better position that many (dare I say most) dialysis patients who still come to dialysis without good, early vascular access preparation.

So … tick #1 to you and your team!

I am glad you also have understood, early and before you have started on your dialysis journey, that frequent dialysis is a huge plus - even though it is an awful thought to have to contemplate - as the results from frequent dialysis are clearly far better than the old, out-moded and poor-outcome associated conventional 3 x weekly regimens. I was about to add there ‘of the past’ … but unfortunately conventional dialysis is still very much ‘of the present’ … so, more strength to your arm - and that of your team - for recognizing that and moving to embrace better dialysis from the start.

So … tick #2 to you and your team!

The NxStage machine has revolutionized dialysis in the US. It has put the options of home, of frequency and even of overnight dialysis back on the agenda. It is to be roundly praised for enlightening the darkness in the US and offering better care to so many who otherwise would not have had access to it. As a machine for long, slow, frequent overnight dialysis, it still has some drawbacks - no machine will ever be perfect or fill all gaps equally … but for the purposes you plan - frequent evening therapy (try to get 5-6 evenings x a minimum … a MINIMUM … of 2.5-3 hours/session) at home - it is well-designed and effective and a good choice to take you forward.

So … tick #3 to you and your team!

As for your question re what to do (once you are on dialysis) to optimize your cardiovascular health … this is a huge question. and I have dealt with much of it in several previous discussions where I have dealt with volume and fluids.

Dealt with time and frequency - though you have already come to the right conclusions about this yourself - in my 1st response to the post … “Is 2.5 hrs 3 x week enough?” … and I discussed care of the access in my 1st response to the post … “Preventative access care”.

As for other measures (like phosphate control) … you have already gone a good distance to ensuring this by electing frequent and more dialysis though this, too, has been discussed in previous responses … “What factors determine optimal nocturnal HD?” … to vitamin supplements at … “Fiber and Vitamin Supplements” … and in several responses by several people in … “Nutrition and exercise”.

Re LVH … the best know way to prevent or, if present, reverse LVH on dialysis is with long, frequent dialysis. Imporvement in aneamia management and control has also been shown to minimize LVH though it still needs to be shown that the recent trends to lower Hb levels of 105-115 g/L sustain the previously demonstrated advantages of attaining a Hb level of 120-125 g/L. However, much more important (in my view) is the better control of interdialytic volume over-stretch and intradialytic volume contraction that accrues from frequent and gentler dialysis … as discussed in previous posts about nocturnal dialysis and its major advantages.

However, if you have any specific questions in this area, I’d be happy to try to answer them.

Hope that has answered some of your questions. I know I have suggested going over old posts - but some of these deal precisely with the issues you have raised.

I have previously discussed with Dori if there are ways to ‘extract’ some of the answers hidden in previous posts to make them more accessible … and I think we are working on that!

I appreciate you telling me which posts to look at for answers to some of my questions; that’s very helpful! You’ve saved me a great deal of time!

I’ve spent a lot of time on many websites learning about dialysis; this site has been the most informative of all, and I appreciate your efforts in this regard. I also am grateful for the reassurance that I am on the right track.

One question - or thought - I did not answer was the effect of the AVF on LV function … and yes, the AVF is (or acts as) a kind of system short circuit - where the blood diverted and ‘looping-back’ through the AVF adds to cardiac output and can induce, in an exaggerated scenario, sufficient additional LV workload to aggravate what is called high output cardiac stress or failure … for the short-circuiting AVF loop adds to work load but, of course, fails to achieve peripheral perfusion.

We published years back,in Nephrology, on this very problem where we looked at AVF >2yrs our after transplantation in well-functioning transplants to assess their aerobic and anaerobic impact on exercise tolerance and showed a significant benefit to exercise tolerance using CPX techniques and echo performance when soft closing the AVF c/w exercise tolerance with the AVF open.

In a dialysis patient, there is little debate … a fistula is needed and even though it may ‘steal’ from cardiac output, it is still preferrable to a catheter (which, of course, does not).

But - an excellent question and one which, in some patients, can present a true clinical problem and conundrum.